What is the management of a port site hernia?

Management of Port Site Hernia

Port site hernias should be surgically repaired, with the approach determined by the presence of complications such as strangulation or incarceration. 1, 2

Clinical Presentation and Diagnosis

Port site hernias develop through inadequate or non-repaired fascial or peritoneal layers following laparoscopic surgery. They can present with:

• Abdominal pain (often localized to the port site)
• Palpable mass at the previous port site
• Signs of bowel obstruction (nausea, vomiting, abdominal distension)
• Elevated white blood cell count and inflammatory markers in cases of strangulation 3

Diagnostic workup should include:

• CT scan with contrast (gold standard for confirming diagnosis)
• Assessment for signs of strangulation (severe pain, fever, leukocytosis)
• Evaluation of hemodynamic stability

Surgical Management Algorithm

1. Emergency Repair (Strangulated/Incarcerated Hernia)

• Indication: Signs of strangulation (severe pain, fever, leukocytosis) or incarceration
• Approach: Open surgical approach via limited incision at the port site
• Technique:
  • Extend the port site incision as needed
  • Assess bowel viability
  • Perform bowel resection if necrosis is present
  • Primary repair of fascial defect with non-absorbable sutures 1, 4, 3

2. Elective Repair (Non-complicated Hernia)

• Approach: Laparoscopic or open repair based on hernia size and patient factors
• Technique options:
  • Small defects (<2 cm): Primary suture repair with non-absorbable sutures
  • Larger defects (>2 cm): Mesh reinforcement recommended
  • Contaminated field: Consider biological or biosynthetic mesh 1, 2

Factors Influencing Surgical Approach

1. Hernia size:

   • Fascial defect size significantly impacts repair method
   • Mean fascial defect size for mesh repair (31±24 mm) vs. suture repair (24±32 mm) 2

2. Patient factors:

   • Higher BMI patients (32±9 vs. 27±4) more likely to need mesh repair
   • Patients with cardiac comorbidities benefit from mesh reinforcement 2

3. Presence of contamination:

   • Clean field: Synthetic mesh acceptable
   • Contaminated field: Biological mesh preferred or primary suture repair 1

Technical Considerations

• Mesh should overlap defect edges by 1.5-2.5 cm to prevent recurrence 5
• For laparoscopic repair, careful adhesiolysis is necessary to prevent bowel injury 1
• Operation time is significantly longer with mesh repair (83±47 min) compared to suture repair (40±28 min) 2

Prevention of Port Site Hernias

• Fascial closure of all port sites ≥10 mm is strongly recommended
• 96% of port site hernias occur with trocars ≥10 mm in diameter 2
• Consider fascial closure even for 5 mm ports in lengthy procedures where active manipulation may have enlarged the defect 6
• Special closure devices like the VersaOne™ Fascial Closure System can facilitate reliable closure under direct visualization 7

Postoperative Care

• Monitor for signs of recurrence
• Follow-up imaging at 3-6 months to assess repair integrity
• No significant difference in hospital stay between mesh and suture repair (approximately 3±4 days) 2
• Overall recurrence rate is approximately 9% regardless of repair technique 2

Pitfalls and Caveats

• Richter's hernias (partial bowel wall herniation) can occur at port sites and may be difficult to diagnose
• CT scan helps differentiate between port site hematoma and incarcerated bowel 3
• Most port site hernias present within 10 days of the primary procedure, but delayed presentation is possible 3
• Laparoscopic visualization during repair can help ensure complete reduction and proper closure 7